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The following Technical Information Bulletin was originally prepared by Dawn Marie Teany (Manager, Technical Information Services, Bio-Lab, Inc., Decatur GA) on 31 July 2000.

Nontuberculous mycobacteria (NTM) is a general class of mycobacteria that does not cause human disease. NTM’s unpopular counterpart, mycobacterium tuberculosis, is the organism that causes human tuberculosis. According to the Centres for Disease Control and Prevention (CDC) in the United States, "As a group, NTM are ubiquitous in the environment. Most species are either not pathogenic for humans or are rarely associated with disease. However, some species, such as M. avium, are opportunistic pathogens that are more frequently associated with disease, especially in immunocompromised persons. Epidemiological features and microbiological aspects of NTM disease are poorly understood."

The common name for NTM, "Lifeguard Lung", originated due to lifeguards at indoor swimming pools with water spouts and sprays, waterfalls and water slides who contracted a rare lung disease. The disease developed after the lifeguards breathed in bacteria suspended in water droplets small enough to be inhaled into the lungs. Common symptoms include frequent cough, recurrent wheezing or chest tightness, laboured, difficult breathing and/or fever.

Dr. Cecile Rose, a physician with the National Jewish Medical and Research Centre, gave a report to the American Thoracic Society describing 9 cases of a lung disease caused by NTM. Dr. Rose associated the lung infection with the use of hot tubs located inside of homes, near family rooms, living rooms and bedrooms. It is not clear as to whether the spas in question were maintained properly. The purpose of Dr. Rose’s presentation was to alert other physicians that NTM infections are often misdiagnosed and when certain symptoms are noted, the physicians should inquire about the use or exposure to an "indoor" spa, swimming pool or water fall. NTM infection is self-limiting and, if diagnosed early, can be effectively treated with antibiotics. Dr. Rose speculates that the mode of transmission was through inhalation of aerosols generated by the spa jets in a confined space. Dr. Rose described the water droplets as being small enough to get deep inside the lung where they stimulate an immune reaction. The bacteria may even be dead, but their remnants are still capable of causing an immune reaction in the lung. No association to NTM infections was made with the use of "outdoor" spas.

Based on this information, for indoor spas, swimming pools and water features, the following important issues must be addressed:

1. Proper and adequate ventilation of the area surrounding the pool, spa or water feature: This means there should be good circulation of the air as well as an adequate way to remove the air in the area of the spa and replace it with fresh air. This need for air exchange should be considered when installing a spa inside a home or in the locker room area of a health or fitness club.
2. Proper water maintenance: This includes proper filtration and circulation of the water along with keeping the balance of the water correct.
3. Consistent sanitation: It is extremely important that proper residuals of a sanitiser are maintained at all times, in all parts of the pool or spa. This includes the piping and filter. Home spas include piping that sometimes does not have flow through it for 8 hours or longer. These pipes are prime sites for bacterial growth. Timers should be used to insure flow through all piping of a spa for at least 30 minutes every 8 hours. A sanitiser should be added regularly and residuals tested to ensure that proper levels are maintained. This could mean testing as often as hourly in commercial systems, two or more times daily in residential spas.

The above information is supplied by Bio-Lab and represents its best interpretation of available technical information at the time of preparation. The sole purpose is to supply factual information to Bio-Lab customers. It is not to be taken out of context nor used as support for any other claim not made herein.